Management of Bleeding and Hemolysis

Mauricio G. Cohen, MD, FACC, FSCAIDirector, Cardiac Catheterization Lab

Professor of Medicine

@DrMauricioCohen

Disclosure Statement of Financial Interest

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

Grant/Research Support Abbott Vascular, Boston Scientific, Svelte

Consulting Fees/Honoraria Abiomed / Terumo Medical / Medtronic / Merit Medical / AstraZeneca

Major Stock Shareholder/Equity Accumed

Royalty Income None

Ownership/Founder None

Intellectual Property Rights None

Other Financial Benefit None

European Journal of Heart Failure (2015) 17, 466–467

DAMPs: damage associated molecular patterns

Liver failure

DIC

Ann Thorac Surg 2014;97:610–6

Major or significant bleeding, 40.8% (26.8% to 56.6%)

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Bleeding requiringtransfusion

Vascular Surgery Hemolysis Pericardiocentesis

Euroshock

Uspella

Lauten A et al. Circ Heart Fail. 2013;6:23-30O’Neill WW et al. J Interven Cardiol 2014;27:1–11

N=120Early learning curve 2005-2010Impella 2.5N=154Early learning curve 2009-2012Impella 2.5

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29

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Groinhematoma

Limb ischemia Bleedingaroundcannula

Atrialperforation

Sepsis Coagulopathy Transfusion GI Bleed

TandemHeart Registry (n=117)

J Am Coll Cardiol 2011;57:688–96

Cardiogenic Shock Patients – High Bleeding Risk

• Large bore vascular access• Percutaneous LVADs

• Traumatic insertion of urinary catheters

• Differential Hemolysis• Multiple venipunctures• Multiorgan dysfunction

• Shock liver• GI stress ulcers• Hemodialysis

• Antithrombotic therapies• Anticoagulants• Antiplatelets

• Coagulation abnormalities• Coagulopathy due to shock liver• Thrombocytopenia• VWF loss of function

Critical Care Monitoring in Patients With CS

Van Diepen S et al. Circulation. 2017;136:e232–e268

Patient Blood Management in the CICU• Restrictive transfusion strategies

• Erythrocyte NO biology of stored blood can lead to vasoconstriction, platelet aggregation, and ineffective oxygen delivery, and contribute to inflammation

• Hemoglobin threshold <7 g/dL with target range of 7-9 g/dL• Single-unit RBC transfusions

• Diagnostic blood draws for a patient can lead to up to 70 mL of blood loss on a daily basis

• Normal daily RBC production in a 70-kg healthy adult is around 17.5 mL

• Identify and manage hemolysis• Stress GI ulcer prophylaxis has been recommended in high-risk patients

• Balance with increased risk of pneumonia and C difficile–associated diarrhea

• Thrombocytopenia, coagulopathy and coagulation disorders• Heparin-induced thrombocytopenia

Shander A et al. Transfusion Medicine Reviews 31 (2017) 264–271

Preparedness for Recognitionand Management of Vascular Complications

Use of Covered Stents Coil Embolization

Samal A and White CJ. CCI 2002;57:12–23

Hemolysis

• Passing of RBCs through heart pumps increases shear stress causing hemolysis

• Obstructions due to malpositioning can increase shear force and hemolysis; proper position includes inlet free from obstruction and outflow well above aortic valve leaflets

• Plasma free hemoglobin >27 mg/dL within 24 hours after Impella predictive of hemolysis with sensitivity 75% and specificity 94%

INTERMACS Hemolysis Definition

• Major Hemolysis: A plasma-free hemoglobin value greater than 20 mg/dl or a serum lactate dehydrogenase (LDH) level greater than two and one-half times (2.5x) the upper limits of the normal range at the implanting center occurring after the first 72 hours post-implant and associated withclinical symptoms or findings of hemolysis or abnormal pump function.

• Major Hemolysis requires the presence of one or more of the following conditions:

• Hemoglobinuria (“tea-colored urine”)• Anemia (decrease in hematocrit or hemoglobin level that is out of proportion to

levels explainable by chronic illness or usual post-VAD state)• Hyperbilirubinemia (total bilirubin above 2 mg%, with predominately indirect

component)• Pump malfunction and/or abnormal pump parameters

Recognition of Hemolysis

• All patients who have an acute MCS device should have baseline LDH and pf-Hb checked pre-implant of MCS.

• Check LDH and pf-Hb q8-12hr for first 72hrs to assess DELTA pf-Hb for a more accurate identification of hemolysis

• A few tips on traumatic foley insertions:• A urinalysis can help

• Blood ++ / RBC ++ likely traumatic foley insertion• Blood ++ / RBC (-) more concerning for hemolysis

• Spun urine can also help:• Supernatent clear/red sediment – likely traumatic foley insertion• Supernatent pink/red sediment – more concerning for hemolysis

Check Impella Positioning

• Initial insertion:• To ensure the Impella is properly placed in the cath lab, and not caught in the

mitral valve apparatus, it is recommended to cross the aortic valve with a pigtail catheter, rather than with the wire alone.

• CCU Impella Position Monitoring:• Upon transfer to the CCU, obtain a TTE to ensure proper placement. • Recheck Impella position with ECHO for position alarms or suction alarms• Always re-position the Impella with real-time ECHO guidance

• Correct Position on TEE:• Parasternal long axis transthoracic

echocardiography is the preferred view to limit foreshortening

• The inlet area should be about 3.5 cm below the aortic valve

• Free from the anterior leaflet or the subannular structures

Impella Positioning

• If Re-positioning is required:• Turn Impella to P-2• Support patient pharmacologically as needed• Re-position Impella with real-time echo guidance• Remove slack in drive-line• Resume prior performance level and ensure catheter hasn’t migrated once flow increased

Preferred view for TTE:Parasternal long axis view

Impella Positioning• Trouble-shooting Position:

• If proper position on echo is confirmed and not involved in the mitral subvalvular apparatus:

• Be cognizant that hemolysis can be an indication of incorrect Impella position even if position looks “perfect”

• Inflow cannula interaction with the anterior mitral valve leaflet can occur, even if “perfect position” on echo

• Recommend re-positioning, with trial of slight clock-wise rotation during repositioning under real-time echo guidance

• Optimize Performance Level:• If patient can tolerate a small decrease in performance level, this may help.• If patient cannot tolerate small decrease, consider increasing support level

Mosaic for Correct and Incorrect Position

Correct Position Incorrect Position

Impella Positioning

Position Problem?

Conclusion

• Bleeding and hemolysis are relatively frequent complications of patients treated with MCS for AMICS

• A culture of vigilance is required in the CICU to recognize complications early and manage promptly

AMICS patients are not forgiving

• Establish and implement protocols to prevent complications

70 yo Male Admitted with Cardiogenic Shock

• U/S guided access using micropunctureneedle

• Placed 6 Fr sheath with intent to upsize for Impella access

Access Strategy (continued)

• Significant resistance is felt while advancing the sheath

• Angiographic assessment of iliac vessels showed…

Clinical Course

Patient develops further hypotension, the best immediate course of action is:

1. Apply pressure to the iliac fossa and refer the patient for CT scan

2. Call vascular surgery for open repair

3. Inflate PTA balloon in external iliac artery to prevent further bleeding

4. Fluid resuscitation

5. Central cannulation for LVAD

Clinical Course

• We inflated a ConQuestan 8mmX4cm PTA Balloon in the iliac artery

• Patient stabilized with pressors and fluids

• The best course of action now is?

Best Course of Action?

• Nothing. The perforation sealed with prolonged balloon inflation

• Place a self-expanding stent and seal the perforation

• Now is the time to take the patient to the OR for open vascular repair

• The patient is stable now. It is time to assess the blood loss with a CT scan

Best Course of Action?

• Nothing. The perforation sealed with prolonged balloon inflation

• Place a self-expanding stent and seal the perforation

• Now is the time to take the patient to the OR for open vascular repair

• The patient is stable now. It is time to assess the blood loss with a CT scan

Best Course of Action

10x40 mm Gore Viabahn covered self expanding stent deployed and then post-dilated with 9x60 mm Evercross balloon at 6 atm.